Preventive Medicine 69 (2014) 307–311
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Disparities in tobacco use by sexual orientation among high school students Sunday Azagba a,b,⁎, Mark Asbridge c, Donald Langille c, Bruce Baskerville a,b a b c
Propel Centre for Population Health Impact, University of Waterloo, Canada School of Public Health and Health Systems, University of Waterloo, Canada Department of Community Health and Epidemiology, Dalhousie University, Canada
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Available online 30 October 2014 Keywords: Tobacco use High school students Prevalence Sexual minority Lesbian Gay Bisexual Heterosexual
a b s t r a c t Objective. This study examined whether cigarette use is associated with sexual orientation among high school students. Methods. Data were from a 2012 cross-sectional survey of 5994 students in grades 9, 10 and 12 attending public schools in Atlantic Canada. Multilevel logistic regression analysis was used to examine differences in cigarette use by sexual orientation. Results. Lesbian, gay and bisexual adolescents (LGB) reported higher prevalence (22%) of daily cigarette use compared with heterosexuals (11%). Multilevel logistic regression analysis, controlling for standard covariates, found that LGB adolescents were more likely to be daily smokers than non-LGB adolescents (odds ratio 2.00, 95% confidence interval 1.50–2.68). Bisexual adolescents were at least twice more likely to be a smoker compared with heterosexual adolescents. Conclusions. Prevalence of cigarette use was significantly higher among LGB adolescent students. Our results join a growing body of evidence indicating that sexual minorities are at heightened risk of tobacco use. Smoking cessation measures that specifically target this group may be beneficial given that there is no one size fits all approach. © 2014 Elsevier Inc. All rights reserved.
Introduction Despite decades of scientific evidence of the deleterious effects of tobacco use, smoking remains the main cause of preventable death worldwide (WHO, 2012). The majority of adult long-term smokers initiated smoking during adolescence (Johnston et al., 2012; Chassin et al., 1990; Khuder et al., 1999). Understanding the factors that contribute to smoking initiation during this transition period provides opportunity to reduce the overall disease burden attributable to smoking. While there has been progress in efforts to reduce smoking rates in recent years, at least in developed countries, there are concerns about the rate of smoking among sexual minorities (Marshal et al., 2008; Coker et al., 2010). There is accumulating evidence of high smoking rates among lesbian, gay, and bisexual (LGB) youth (Corliss et al., 2013; Marshal et al., 2008; Rath et al., 2013; Hagger-Johnson et al., 2013; Ortiz-Hernández et al., 2009). A meta-analysis of 18 studies on sexual orientation and adolescent substance use found that LGB adolescents were significantly more likely to report substance use than heterosexual teens (Marshal et al., 2008). ⁎ Corresponding author at: Propel Centre for Population Health Impact, Faculty of Applied Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada. E-mail address: [email protected] (S. Azagba).
http://dx.doi.org/10.1016/j.ypmed.2014.07.042 0091-7435/© 2014 Elsevier Inc. All rights reserved.
Data from the Growing Up Today Study showed that sexual minority youth compared with those who are completely heterosexual were more likely to initiate smoking at a younger age and had higher frequency of smoking (Corliss et al., 2013). There is also evidence that among LGB communities, and especially among lesbian and bisexual women, the marketing efforts of the tobacco industry are more intense and more effective (Dilley et al., 2008; Smith et al., 2006). Much of what is currently known about smoking prevalence among LGB adolescents comes from the United States. Poorer health outcomes among minorities may arise from stress due to prejudice and discrimination (Meyer, 2003), and sexual minority youth in the United States in states with low structural stigma are less likely to smoke (Hatzenbuehler et al., 2014). The level of societal acceptance of same-sex relationships differ between Canada and the United States, given the same-sex marriage legislation implemented across Canada in 2005. The objective of this study is to examine whether there are disparities in tobacco use by sexual orientation in Canadian high school students. Methods Participants The present study is based on the 2012 Student Drug Use Survey in the Atlantic Provinces (SDUSAP). The SDUSAP is a representative cross-sectional
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survey of students in grades 7, 9, 10 and 12 attending public schools in the three Atlantic Provinces of Nova Scotia, New Brunswick, and Newfoundland & Labrador. Public school students in both Anglophone and Francophone schools were included in the sample. Excluded were private schools, schools on indigenous peoples' reserves, street-youth, school-leavers and students who were absent from school on the designated day of the survey. The sample design was a two-stage stratified cluster sample of randomly selected classes containing at least 20 students in each of the four surveyed grades within each health region in the three participating provinces. Parental consent was obtained in one of two ways depending on the school board. Some school boards required active parental consent for their child to take part in the survey, where a signed consent form was to be returned to the school. Other school boards required passive parental consent, whereby parents contacted the school if they did not want their child to take part in the survey. Finally, all students who did participate in the survey also gave individual/personal consent. Ethics approval was granted by the Dalhousie University Health Sciences Research Ethics Board. Ninety percent of students present on the day the survey was administered participated in the SDUSAP. Dependent variable Smoking behavior. Two binary variables that indicated smoking status in the past year were created: 1) current daily smokers represented those that smoked at least one cigarette per day in the past year and 2) ever daily smokers represented those that have smoked 100 or more cigarettes in their life time and had smoked at least one cigarette per day in the past year. Independent variables Sexual orientation was assessed from the question (Hatzenbuehler et al., 2014; Corliss et al., 2013): “Which of the following best describes your feelings? With response options of: i) 100% heterosexual (attracted to persons of the opposite sex), ii) mostly heterosexual, iii) bisexual (attracted to both males and females), iv) mostly homosexual, v) 100% homosexual (gay/lesbian; attracted to person of the same sex), and, vi) not sure. The “100% homosexual”, “mostly homosexual”, and “bisexual” responses were combined to form the LGB group. The “not sure” responses were excluded in the analysis. The analysis also controlled for health and socio-demographic variables. Age was represented in continuous form (number of years). Sex (are you male or female?) was coded 1 for males and 0 for females. Parental (mother) education was categorized as post-secondary education, unknown, and less than postsecondary education (reference category). Due to sample size restrictions, students' living arrangement was coded as living with both parents vs. not living with both parents. Risk of depression was measured using a 12 item version of the Centers for Epidemiological Studies Depression Scale (CES-D) (Cronbach's alpha = 0.87) with a higher score indicating increased risk of depressive symptoms. We created three categories of depressive symptoms: very elevated (CES-D score 21 to 36), somewhat (CES-D score 12 to 20) and minimal (CES-D score 0 to 11) (Poulin et al., 2005). Sensation seeking among adolescents was measured using 4 items (Stephenson et al., 2003). Frequency of alcohol use was coded 1 for those that reported drinking alcohol at least once a week in the past year and 0 otherwise. Statistical analysis Given the nested structure of our data (students within school), multilevel logistic regression analysis was used to examine the disparities in cigarette use by sexual orientation. First, we determine between-school variability in smoking by estimating a null or empty model and an intraclass correlation ! σ 22 is calculated. The null specification indicated statistically ρ ¼ π2 þ σ 22 3 significant between-school variability (ρ = 0.1589, p b 0.001) in smoking. In the main analysis, examining the association between smoking and sexual attraction (LGB vs heterosexual), we minimally adjusted for age and sex, and then adjusted for all covariates. Model fit from a multilevel random intercept model and a model that allows a random slope on LGB were compared using a likelihood ratio test. The random slope model was not significantly different from the random intercept. Results from the random intercept model are reported in this study. We also separated LGB into lesbian or gay (LG) and bisexual in order not to mask the differences between LG and bisexuals (Hagger-Johnson et al., 2013; Barker et al., 2012; Saewyc, 2011; McCabe et al., 2005), however, these results should be interpreted with caution due to small sample size. To determine effect modification by sex, a likelihood ratio test was performed for a model containing LGB, age and sex and a model that additionally
contained an interaction term between LGB and sex. Also, significant effect modification by sex was found, therefore, analyses were stratified. We did not find any evidence of effect modification by socioeconomic status (mother education). All analyses are restricted to students in high school (grades 9, 10 and 12). Excluded from the analysis were the responses of students who reported using a fictitious drug, which was included in the survey to detect students not responding in a trustworthy fashion.
Results Unweighted summary statistics for study variables are reported in Table 1. Of the 5994 high school students (grades 9, 10, 12), based on self-reported sexual attraction, about 93.8% (n = 5626) were classified as heterosexual, 4.4% (n = 263) were bisexual, and 1.8% (n = 105) were lesbian or gay. In the weighted descriptive analysis, 6.7% were LGB and 93.7% were heterosexual. The weighted prevalence estimates for cigarette use among adolescent students showed that approximately 22% of sexual minority students (LGB) reported daily cigarette use compared with 11% of heterosexuals Similar results were found for the prevalence of established smoking (LGB, 16% versus Heterosexual, 8%). The results of the multilevel regression, reported in Table 2, indicate a statistically significant association between cigarette use and sexual orientation among high school students in Atlantic Canada. The minimally unadjusted analysis showed that LGB students compared to heterosexual students were more likely to be daily smokers (odds ratio [OR] 2.41, 95% confidence interval [CI] 1.83–3.17). Likewise, LGB students had higher odds of being daily smokers after controlling for age, sex, alcohol use, parent's education, living arrangement, sensation seeking, and risk of depression (OR 2.00, CI 1.50–2.68). The results show similar association between being an established cigarette smoker and sexual orientation. LGB students were significantly more likely to be established smokers than heterosexuals (minimally adjusted: OR 2.21, CI 1.63–3.01; fully adjusted; OR 1.87, CI 1.35–2.58). Analysis comparing lesbian or gay students versus heterosexual, and bisexual versus heterosexual are reported in Model 2. While the odds of being a smoker is higher for lesbian or gay students compared to heterosexual both in the minimally and fully adjusted models, the results were not statistically significant. Bisexual students were more likely to be a smoker compared to heterosexuals. In the minimally adjusted model, bisexuals were approximately 3.1 and 2.7 times more likely to be a daily smoker and established smoker respectively when compared to heterosexuals. These results remained statistically significant in the fully adjusted models. Analyses stratified by sex are shown in Table 3. The results were largely different for males and females. While the results for females basically mirrored the results shown for the unstratified analysis in Table 2, the association was stronger for females. Lesbian or bisexual females were significantly more likely to be daily cigarette smokers than heterosexuals (OR 3.84, CI 2.72–5.41). In the fully adjusted model, higher odds of smoking were found for lesbian or bisexual students (OR 2.63, CI 1.83–3.78). Separate analyses comparing lesbians versus heterosexuals and bisexuals versus heterosexuals are shown in Model 2. Bisexual students had higher odds of reporting daily cigarette use in the past year when compared with heterosexuals (minimally adjusted: OR 4.39, CI 3.03–6.36; fully adjusted: OR 2.85, CI 1.93–4.21). There was no statistically significant difference in being a smoker between lesbians and heterosexuals with the exception of the minimally adjusted models, which were marginally significant. Among males, sexual orientation (gay or bisexual versus heterosexual, gay versus heterosexual, and bisexual versus heterosexual) was not significantly associated with smoking status. Discussion Identifying a subpopulation with heightened risk of tobacco use can inform an effective prevention strategy. One such population with
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Table 1 Unweighted sample characteristics by sexual orientation.
Gender Male Female Age Parental education Post-secondary bPost-secondary Not stated Living arrangement Not with both parents With both parents Depressive symptoms Very elevated Somewhat elevated Minimal Sensation seeking Cigarette and alcohol use Daily cigarette smoker Non-daily smoker Established cigarette smoker Non-established smoker Frequency of alcohol use ≥once a week Frequency of alcohol use bonce a week a
Non-LGB (n = 5626, 93.9%)
LGB (n = 368, 6.1%)
Heterosexual n (%)
Lesbian or gay n (%)
Bisexual n (%)
Combined n (%)
2722 (48.4) 2904 (51.6) 5626 (15.9)a
59 (56.2) 46 (43.8) 105 (16.3)a
71 (27.0) 192 (73.0) 263 (16.1)a
238 (64.7) 130 (35.3) 368 (16.2)a
3334 (59.3) 1445 (25.7) 847 (15.1)
62 (59.1) 29 (27.6) 14 (13.3)
121 (46.0) 52 (19.8) 90 (34.2)
183 (49.7) 119 (32.3) 66 (17.9)
3709 (65.9) 1917 (34.1)
43 (41.0) 62 (59.0)
148 (56.3) 115 (43.7)
191 (51.9) 177 (48.1)
441 (7.8) 1373 (24.4) 3812 (67.8) 5626 (10.9)a
24 (22.9) 35 (33.3) 46 (43.8) 105 (11.4)a
80 (30.4) 102 (38.8) 81 (30.8) 263 (12.0)a
104 (28.3) 137 (37.2) 127 (34.5) 368 (11.9)a
652 (11.6) 4974 (88.4) 495 (8.8) 5131 (91.2) 837 (14.9) 4789 (85.1)
18 (17.1) 87 (82.7) 15 (14.3) 90 (85.7) 10 (9.5) 95 (90.5)
72 (27.4) 191 (72.6) 212 (80.6) 51 (19.4) 33 (12.6) 230 (87.5)
90 (24.5) 278 (75.5) 66 (17.9) 302 (82.1) 43 (11.7) 325 (88.3)
Values represent mean of a continuous variable.
Table 2 Association between tobacco use and sexual orientation among high school students. Daily cigarette smoker
Established cigarette smoker
Minimally adjusteda
Fully adjustedb
Minimally adjusteda
Fully adjustedb
Model 1 Lesbian, gay or bisexual (vs heterosexual)
2.41 (1.83–3.17)
2.00 (1.50–2.68)
2.21 (1.63–3.01)
1.87 (1.35–2.58)
Model 2 Lesbian or gay (vs heterosexual) Bisexual (vs heterosexual)
1.25 (0.72–2.16) 3.06 (2.24–4.19)
1.33 (0.75–2.37) 2.27 (1.63–3.16)
1.31 (0.73–2.37) 2.71 (1.91–3.85)
1.41 (0.76–2.62) 2.04 (1.41–2.94)
Daily smokers represented those that smoked at least one cigarette per day in the past year. Established smokers represented those that have smoked 100 or more cigarettes in their life time and had smoked at least one cigarette per day in the past year. Values shown are adjusted odds ratios (95% confidence intervals). a Adjusted for age and sex. b Adjusted for age, sex, alcohol use, parent's education, living arrangement, sensation seeking, and risk of depression.
Table 3 Association between tobacco use and sexual orientation among high school students by gender. Daily cigarette smoker
Established cigarette smoker
Minimally adjusted⁎
Fully adjusted⁎⁎
Minimally adjusted⁎⁎
Fully adjusted⁎⁎
1.14 (0.69–1.89)
1.26 (0.74–2.13)
0.90 (0.50–1.61)
0.98 (0.54–1.80)
0.91 (0.42–1.96) 1.36 (0.71–2.63)
1.23 (0.55–2.74) 1.28 (0.64–2.53)
0.86 (0.37–2.01) 0.91 (0.41–2.02)
1.16 (0.48–2.79) 0.86 (0.38–1.95)
Females (n = 3142) Model 1 Lesbian or bisexual (vs heterosexual)
3.84 (2.72–5.41)
2.63 (1.83–3.78)
3.85 (2.64–5.61)
2.61 (1.75–3.90)
Model 2 Lesbian (vs heterosexual) Bisexual (vs heterosexual)
2.03 (0.90–4.55) 4.39 (3.03–6.36)
1.67 (0.71–3.93) 2.85 (1.93–4.21)
2.40 (1.02–5.65) 4.28 (2.85–6.42)
1.93 (0.76–4.89) 2.77 (1.80–4.26)
Males (n = 2852) Model 1 Gay or bisexual (vs heterosexual) Model 2 Gay (vs heterosexual) Bisexual (vs heterosexual)
Daily smokers represented those that smoked at least one cigarette per day in the past year. Established smokers represented those that have smoked 100 or more cigarettes in their life time and had smoked at least one cigarette per day in the past year. Values shown are adjusted odds ratios (95% confidence intervals). ⁎ Adjusted for age. ⁎⁎ Adjusted for age, alcohol use, parent's education, living arrangement, sensation seeking, and risk of depression.
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unique health needs include sexual minorities (Institute of Medicine, 2011). In a representative sample of high school students from Atlantic Canada, the prevalence of cigarette use in the past year was twice as high among LGB than heterosexual adolescents. About 17% of LGB were ever daily smokers compared to 8% of non-LGB students. In the adjusted analysis, LGB students were significantly more likely to report daily cigarette use in the last year. The results shown in this study are largely consistent with the findings reported in previous adolescents' studies (Coker et al., 2010; Corliss et al., 2013; Marshal et al., 2008; Hagger-Johnson et al., 2013) and among young adults (Rath et al., 2013). In keeping with studies showing sex to be an important modifier of the association between substance use and sexual orientation (Hahm et al., 2008; Corliss et al., 2010, 2013), evidence of effect modification by sex was found in the present study. In addition, bisexual females had greater risk of tobacco use compared to heterosexual females and no significant difference was found between gay or bisexual males and heterosexual males. Using a community-based sample of US adolescents, Austin et al. (2004) found similar results among gay or bisexual boys. The preponderance of research suggests that emotional distress may in part help to explain the health disparities among sexual minorities (Almeida et al., 2009; Coker et al., 2010; Hatzenbuehler et al., 2014; Marshal et al., 2008; Meyer, 2003). Minority stress theory posits that poorer health outcomes among stigmatized minority groups are a result of excess stress due to stigma, prejudice and discrimination (Meyer, 2003). Prospective data from the Growing Up Today Study found that sexual minority youth in the United States living in states with low structural stigma were less likely to report cigarette use in the past year (Hatzenbuehler et al., 2014). Furthermore, a recent study on the role of structural stigma on substance use among sexual minority youth found that exposure to structural stigma was significantly associated with daily cigarette use (Pachankis et al., 2014). According to survey selfreport data, LGB youth were more likely to have experienced sexual abuse, parental abuse, assault at school when compared to non-LGB peers (Saewyc et al., 2006; Bontempo and d'Augelli, 2002). Such abuse has an effect on negative health behaviors, making this population more vulnerable to substance abuse (Friedman et al., 2011). Research has found that students who attended schools with more supportive environment for sexual minorities were significantly less likely to report substance use and emotional distress (Heck et al., 2011, 2014; Konishi et al., 2013). Independent research also note that tobacco industry has historically targeted sexual minority populations (Dilley et al., 2008; Washington, 2002; Smith et al., 2006, 2008; Smith et al., 2008). This study has limitations. We used sexual attraction as a measure of sexual orientation, while other measures, including sexual behavior and self-identity are available (Austin et al., 2007). Saewyc et al. (2004), in considering the pros and cons of these various measures, point out that while multiple measures are most appropriate for such research, where outcomes other than sexual behaviors are being considered, non-heterosexual behavior as a measure of orientation can exclude students who are attracted to the opposite sex and/or self-identify as non-heterosexual, but who are not yet sexually active. Saewyc and colleagues also indicates that self-identity generally follows attraction, so that if self-identity is used as a measure, some of those at risk of behaviors associated with orientation (as measured by attraction) will not be included, concluding that where survey length makes possible inclusion of only one measure, attraction is probably the best choice. In addition to this limitation, the SDUSAP is a cross-sectional survey of students in Atlantic Canada, which limits us from making causal inference. Finally, our regional results may not be generalizable to adolescents in other parts of Canada and comparability of our findings with other studies may be limited due to different ways of assessing sexual orientation (Saewyc et al., 2004; Saewyc, 2011).
Conclusion Prevalence estimates for cigarette use were significantly higher among LGB adolescent students. Notwithstanding Canada having same-sex marriage legislation since 2005, our findings are largely consistent with US based studies. These results join a growing body of evidence indicating that sexual minorities are at heightened risk of tobacco use. Smoking cessation measures that specifically target this group in ways that address their minority sexual orientation may be beneficial. While the empirical evidence of the benefits of gay-straight alliances in schools are accumulating (Heck et al., 2014), future research should address the knowledge deficit concerning culturally appropriate and effective tobacco prevention and cessation efforts for sexual minority community (Saewyc, 2011; Doolan and Froelicher, 2006). One study of 733 lesbian, gay, bisexual, and transgender youth in Canada and the United States revealed that youth felt it important that providers address the need for greater sensitivity to developmental and cultural differences among non-heterosexual youth as well as health promotions and assessment of health risks (Hoffman et al., 2009). Conflict of interest statement The authors declare that there are no conflicts of interests.
Funding This research was supported by research grants from the Canadian Cancer Society Research Institute (Grant Number 2011-701019) and the Nova Scotia Health Research Foundation (Grant PSO-EXT-20118431). Funding for data collection was provided in part by the provincial Departments of Health and Wellness in Nova Scotia, New Brunswick, Newfoundland and Labrador. References Almeida, J., Johnson, R.M., Corliss, H.L., Molnar, B.E., Azrael, D., 2009. Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. J. Youth Adolesc. 38 (7), 1001–1014. Austin, S.B., Ziyadeh, N., Fisher, L.B., Kahn, J.A., Colditz, G.A., Frazier, A.L., 2004. Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Arch. Pediatr. Adolesc. Med. 158 (4), 317–322. Austin, S.B., Conron, K.J., Patel, A., Freedner, N., 2007. Making sense of sexual orientation measures: findings from a cognitive processing study with adolescents on health survey questions. J. LBGT Health Res. 3 (1), 55–65. Barker, M., Yockney, J., Richards, C., Jones, R., Bowes-Catton, H., Plowman, T., 2012. Guidelines for researching and writing about bisexuality. J. Bisexuality 12 (3), 376–392. Bontempo, D.E., d'Augelli, A.R., 2002. Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths' health risk behavior. J. Adolesc. Health 30 (5), 364–374. Chassin, L., Presson, C.C., Sherman, S.J., Edwards, D.A., 1990. The natural history of cigarette smoking: predicting young-adult smoking outcomes from adolescent smoking patterns. Health Psychol. 9 (6), 701–716. Coker, T.R., Austin, S.B., Schuster, M.A., 2010. The health and health care of lesbian, gay, and bisexual adolescents. Annu. Rev. Public Health 31, 457–477. Corliss, H.L., Rosario, M., Wypij, D., Wylie, S.A., Frazier, A.L., Austin, S.B., 2010. Sexual orientation and drug use in a longitudinal cohort study of US adolescents. Addict. Behav. 35 (5), 517–521. Corliss, H.L., Wadler, B.M., Jun, H.J., et al., 2013. Sexual-orientation disparities in cigarette smoking in a longitudinal cohort study of adolescents. Nicotine Tob. Res. 15 (1), 213–222. Dilley, J.A., Spigner, C., Boysun, M.J., Dent, C.W., Pizacani, B.A., 2008. Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities? Tob. Control. 17 (6), 385–390. Doolan, D.M., Froelicher, E.S., 2006. Efficacy of smoking cessation intervention among special populations: review of the literature from 2000 to 2005. Nurs. Res. 55 (4), S29–S37. Friedman, M.S., Marshal, M.P., Guadamuz, T.E., et al., 2011. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. Am. J. Public Health 101 (8). Hagger-Johnson, G., Taibjee, R., Semlyen, J., et al., 2013. Sexual orientation identity in relation to smoking history and alcohol use at age 18/19: cross-sectional associations from the Longitudinal Study of Young People in England (LSYPE). BMJ Open 3 (8), e002810. Hahm, H.C., Wong, F.Y., Huang, Z.J., Ozonoff, A., Lee, J., 2008. Substance use among Asian Americans and Pacific Islanders sexual minority adolescents: findings from the National Longitudinal Study of Adolescent Health. J. Adolesc. Health 42 (3), 275–283.
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Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Disparities in tobacco use by sexual orientation among high school students Sunday Azagba a,b,⁎, Mark Asbridge c, Donald Langille c, Bruce Baskerville a,b a b c
Propel Centre for Population Health Impact, University of Waterloo, Canada School of Public Health and Health Systems, University of Waterloo, Canada Department of Community Health and Epidemiology, Dalhousie University, Canada
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Available online 30 October 2014 Keywords: Tobacco use High school students Prevalence Sexual minority Lesbian Gay Bisexual Heterosexual
a b s t r a c t Objective. This study examined whether cigarette use is associated with sexual orientation among high school students. Methods. Data were from a 2012 cross-sectional survey of 5994 students in grades 9, 10 and 12 attending public schools in Atlantic Canada. Multilevel logistic regression analysis was used to examine differences in cigarette use by sexual orientation. Results. Lesbian, gay and bisexual adolescents (LGB) reported higher prevalence (22%) of daily cigarette use compared with heterosexuals (11%). Multilevel logistic regression analysis, controlling for standard covariates, found that LGB adolescents were more likely to be daily smokers than non-LGB adolescents (odds ratio 2.00, 95% confidence interval 1.50–2.68). Bisexual adolescents were at least twice more likely to be a smoker compared with heterosexual adolescents. Conclusions. Prevalence of cigarette use was significantly higher among LGB adolescent students. Our results join a growing body of evidence indicating that sexual minorities are at heightened risk of tobacco use. Smoking cessation measures that specifically target this group may be beneficial given that there is no one size fits all approach. © 2014 Elsevier Inc. All rights reserved.
Introduction Despite decades of scientific evidence of the deleterious effects of tobacco use, smoking remains the main cause of preventable death worldwide (WHO, 2012). The majority of adult long-term smokers initiated smoking during adolescence (Johnston et al., 2012; Chassin et al., 1990; Khuder et al., 1999). Understanding the factors that contribute to smoking initiation during this transition period provides opportunity to reduce the overall disease burden attributable to smoking. While there has been progress in efforts to reduce smoking rates in recent years, at least in developed countries, there are concerns about the rate of smoking among sexual minorities (Marshal et al., 2008; Coker et al., 2010). There is accumulating evidence of high smoking rates among lesbian, gay, and bisexual (LGB) youth (Corliss et al., 2013; Marshal et al., 2008; Rath et al., 2013; Hagger-Johnson et al., 2013; Ortiz-Hernández et al., 2009). A meta-analysis of 18 studies on sexual orientation and adolescent substance use found that LGB adolescents were significantly more likely to report substance use than heterosexual teens (Marshal et al., 2008). ⁎ Corresponding author at: Propel Centre for Population Health Impact, Faculty of Applied Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada. E-mail address: [email protected] (S. Azagba).
http://dx.doi.org/10.1016/j.ypmed.2014.07.042 0091-7435/© 2014 Elsevier Inc. All rights reserved.
Data from the Growing Up Today Study showed that sexual minority youth compared with those who are completely heterosexual were more likely to initiate smoking at a younger age and had higher frequency of smoking (Corliss et al., 2013). There is also evidence that among LGB communities, and especially among lesbian and bisexual women, the marketing efforts of the tobacco industry are more intense and more effective (Dilley et al., 2008; Smith et al., 2006). Much of what is currently known about smoking prevalence among LGB adolescents comes from the United States. Poorer health outcomes among minorities may arise from stress due to prejudice and discrimination (Meyer, 2003), and sexual minority youth in the United States in states with low structural stigma are less likely to smoke (Hatzenbuehler et al., 2014). The level of societal acceptance of same-sex relationships differ between Canada and the United States, given the same-sex marriage legislation implemented across Canada in 2005. The objective of this study is to examine whether there are disparities in tobacco use by sexual orientation in Canadian high school students. Methods Participants The present study is based on the 2012 Student Drug Use Survey in the Atlantic Provinces (SDUSAP). The SDUSAP is a representative cross-sectional
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survey of students in grades 7, 9, 10 and 12 attending public schools in the three Atlantic Provinces of Nova Scotia, New Brunswick, and Newfoundland & Labrador. Public school students in both Anglophone and Francophone schools were included in the sample. Excluded were private schools, schools on indigenous peoples' reserves, street-youth, school-leavers and students who were absent from school on the designated day of the survey. The sample design was a two-stage stratified cluster sample of randomly selected classes containing at least 20 students in each of the four surveyed grades within each health region in the three participating provinces. Parental consent was obtained in one of two ways depending on the school board. Some school boards required active parental consent for their child to take part in the survey, where a signed consent form was to be returned to the school. Other school boards required passive parental consent, whereby parents contacted the school if they did not want their child to take part in the survey. Finally, all students who did participate in the survey also gave individual/personal consent. Ethics approval was granted by the Dalhousie University Health Sciences Research Ethics Board. Ninety percent of students present on the day the survey was administered participated in the SDUSAP. Dependent variable Smoking behavior. Two binary variables that indicated smoking status in the past year were created: 1) current daily smokers represented those that smoked at least one cigarette per day in the past year and 2) ever daily smokers represented those that have smoked 100 or more cigarettes in their life time and had smoked at least one cigarette per day in the past year. Independent variables Sexual orientation was assessed from the question (Hatzenbuehler et al., 2014; Corliss et al., 2013): “Which of the following best describes your feelings? With response options of: i) 100% heterosexual (attracted to persons of the opposite sex), ii) mostly heterosexual, iii) bisexual (attracted to both males and females), iv) mostly homosexual, v) 100% homosexual (gay/lesbian; attracted to person of the same sex), and, vi) not sure. The “100% homosexual”, “mostly homosexual”, and “bisexual” responses were combined to form the LGB group. The “not sure” responses were excluded in the analysis. The analysis also controlled for health and socio-demographic variables. Age was represented in continuous form (number of years). Sex (are you male or female?) was coded 1 for males and 0 for females. Parental (mother) education was categorized as post-secondary education, unknown, and less than postsecondary education (reference category). Due to sample size restrictions, students' living arrangement was coded as living with both parents vs. not living with both parents. Risk of depression was measured using a 12 item version of the Centers for Epidemiological Studies Depression Scale (CES-D) (Cronbach's alpha = 0.87) with a higher score indicating increased risk of depressive symptoms. We created three categories of depressive symptoms: very elevated (CES-D score 21 to 36), somewhat (CES-D score 12 to 20) and minimal (CES-D score 0 to 11) (Poulin et al., 2005). Sensation seeking among adolescents was measured using 4 items (Stephenson et al., 2003). Frequency of alcohol use was coded 1 for those that reported drinking alcohol at least once a week in the past year and 0 otherwise. Statistical analysis Given the nested structure of our data (students within school), multilevel logistic regression analysis was used to examine the disparities in cigarette use by sexual orientation. First, we determine between-school variability in smoking by estimating a null or empty model and an intraclass correlation ! σ 22 is calculated. The null specification indicated statistically ρ ¼ π2 þ σ 22 3 significant between-school variability (ρ = 0.1589, p b 0.001) in smoking. In the main analysis, examining the association between smoking and sexual attraction (LGB vs heterosexual), we minimally adjusted for age and sex, and then adjusted for all covariates. Model fit from a multilevel random intercept model and a model that allows a random slope on LGB were compared using a likelihood ratio test. The random slope model was not significantly different from the random intercept. Results from the random intercept model are reported in this study. We also separated LGB into lesbian or gay (LG) and bisexual in order not to mask the differences between LG and bisexuals (Hagger-Johnson et al., 2013; Barker et al., 2012; Saewyc, 2011; McCabe et al., 2005), however, these results should be interpreted with caution due to small sample size. To determine effect modification by sex, a likelihood ratio test was performed for a model containing LGB, age and sex and a model that additionally
contained an interaction term between LGB and sex. Also, significant effect modification by sex was found, therefore, analyses were stratified. We did not find any evidence of effect modification by socioeconomic status (mother education). All analyses are restricted to students in high school (grades 9, 10 and 12). Excluded from the analysis were the responses of students who reported using a fictitious drug, which was included in the survey to detect students not responding in a trustworthy fashion.
Results Unweighted summary statistics for study variables are reported in Table 1. Of the 5994 high school students (grades 9, 10, 12), based on self-reported sexual attraction, about 93.8% (n = 5626) were classified as heterosexual, 4.4% (n = 263) were bisexual, and 1.8% (n = 105) were lesbian or gay. In the weighted descriptive analysis, 6.7% were LGB and 93.7% were heterosexual. The weighted prevalence estimates for cigarette use among adolescent students showed that approximately 22% of sexual minority students (LGB) reported daily cigarette use compared with 11% of heterosexuals Similar results were found for the prevalence of established smoking (LGB, 16% versus Heterosexual, 8%). The results of the multilevel regression, reported in Table 2, indicate a statistically significant association between cigarette use and sexual orientation among high school students in Atlantic Canada. The minimally unadjusted analysis showed that LGB students compared to heterosexual students were more likely to be daily smokers (odds ratio [OR] 2.41, 95% confidence interval [CI] 1.83–3.17). Likewise, LGB students had higher odds of being daily smokers after controlling for age, sex, alcohol use, parent's education, living arrangement, sensation seeking, and risk of depression (OR 2.00, CI 1.50–2.68). The results show similar association between being an established cigarette smoker and sexual orientation. LGB students were significantly more likely to be established smokers than heterosexuals (minimally adjusted: OR 2.21, CI 1.63–3.01; fully adjusted; OR 1.87, CI 1.35–2.58). Analysis comparing lesbian or gay students versus heterosexual, and bisexual versus heterosexual are reported in Model 2. While the odds of being a smoker is higher for lesbian or gay students compared to heterosexual both in the minimally and fully adjusted models, the results were not statistically significant. Bisexual students were more likely to be a smoker compared to heterosexuals. In the minimally adjusted model, bisexuals were approximately 3.1 and 2.7 times more likely to be a daily smoker and established smoker respectively when compared to heterosexuals. These results remained statistically significant in the fully adjusted models. Analyses stratified by sex are shown in Table 3. The results were largely different for males and females. While the results for females basically mirrored the results shown for the unstratified analysis in Table 2, the association was stronger for females. Lesbian or bisexual females were significantly more likely to be daily cigarette smokers than heterosexuals (OR 3.84, CI 2.72–5.41). In the fully adjusted model, higher odds of smoking were found for lesbian or bisexual students (OR 2.63, CI 1.83–3.78). Separate analyses comparing lesbians versus heterosexuals and bisexuals versus heterosexuals are shown in Model 2. Bisexual students had higher odds of reporting daily cigarette use in the past year when compared with heterosexuals (minimally adjusted: OR 4.39, CI 3.03–6.36; fully adjusted: OR 2.85, CI 1.93–4.21). There was no statistically significant difference in being a smoker between lesbians and heterosexuals with the exception of the minimally adjusted models, which were marginally significant. Among males, sexual orientation (gay or bisexual versus heterosexual, gay versus heterosexual, and bisexual versus heterosexual) was not significantly associated with smoking status. Discussion Identifying a subpopulation with heightened risk of tobacco use can inform an effective prevention strategy. One such population with
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Table 1 Unweighted sample characteristics by sexual orientation.
Gender Male Female Age Parental education Post-secondary bPost-secondary Not stated Living arrangement Not with both parents With both parents Depressive symptoms Very elevated Somewhat elevated Minimal Sensation seeking Cigarette and alcohol use Daily cigarette smoker Non-daily smoker Established cigarette smoker Non-established smoker Frequency of alcohol use ≥once a week Frequency of alcohol use bonce a week a
Non-LGB (n = 5626, 93.9%)
LGB (n = 368, 6.1%)
Heterosexual n (%)
Lesbian or gay n (%)
Bisexual n (%)
Combined n (%)
2722 (48.4) 2904 (51.6) 5626 (15.9)a
59 (56.2) 46 (43.8) 105 (16.3)a
71 (27.0) 192 (73.0) 263 (16.1)a
238 (64.7) 130 (35.3) 368 (16.2)a
3334 (59.3) 1445 (25.7) 847 (15.1)
62 (59.1) 29 (27.6) 14 (13.3)
121 (46.0) 52 (19.8) 90 (34.2)
183 (49.7) 119 (32.3) 66 (17.9)
3709 (65.9) 1917 (34.1)
43 (41.0) 62 (59.0)
148 (56.3) 115 (43.7)
191 (51.9) 177 (48.1)
441 (7.8) 1373 (24.4) 3812 (67.8) 5626 (10.9)a
24 (22.9) 35 (33.3) 46 (43.8) 105 (11.4)a
80 (30.4) 102 (38.8) 81 (30.8) 263 (12.0)a
104 (28.3) 137 (37.2) 127 (34.5) 368 (11.9)a
652 (11.6) 4974 (88.4) 495 (8.8) 5131 (91.2) 837 (14.9) 4789 (85.1)
18 (17.1) 87 (82.7) 15 (14.3) 90 (85.7) 10 (9.5) 95 (90.5)
72 (27.4) 191 (72.6) 212 (80.6) 51 (19.4) 33 (12.6) 230 (87.5)
90 (24.5) 278 (75.5) 66 (17.9) 302 (82.1) 43 (11.7) 325 (88.3)
Values represent mean of a continuous variable.
Table 2 Association between tobacco use and sexual orientation among high school students. Daily cigarette smoker
Established cigarette smoker
Minimally adjusteda
Fully adjustedb
Minimally adjusteda
Fully adjustedb
Model 1 Lesbian, gay or bisexual (vs heterosexual)
2.41 (1.83–3.17)
2.00 (1.50–2.68)
2.21 (1.63–3.01)
1.87 (1.35–2.58)
Model 2 Lesbian or gay (vs heterosexual) Bisexual (vs heterosexual)
1.25 (0.72–2.16) 3.06 (2.24–4.19)
1.33 (0.75–2.37) 2.27 (1.63–3.16)
1.31 (0.73–2.37) 2.71 (1.91–3.85)
1.41 (0.76–2.62) 2.04 (1.41–2.94)
Daily smokers represented those that smoked at least one cigarette per day in the past year. Established smokers represented those that have smoked 100 or more cigarettes in their life time and had smoked at least one cigarette per day in the past year. Values shown are adjusted odds ratios (95% confidence intervals). a Adjusted for age and sex. b Adjusted for age, sex, alcohol use, parent's education, living arrangement, sensation seeking, and risk of depression.
Table 3 Association between tobacco use and sexual orientation among high school students by gender. Daily cigarette smoker
Established cigarette smoker
Minimally adjusted⁎
Fully adjusted⁎⁎
Minimally adjusted⁎⁎
Fully adjusted⁎⁎
1.14 (0.69–1.89)
1.26 (0.74–2.13)
0.90 (0.50–1.61)
0.98 (0.54–1.80)
0.91 (0.42–1.96) 1.36 (0.71–2.63)
1.23 (0.55–2.74) 1.28 (0.64–2.53)
0.86 (0.37–2.01) 0.91 (0.41–2.02)
1.16 (0.48–2.79) 0.86 (0.38–1.95)
Females (n = 3142) Model 1 Lesbian or bisexual (vs heterosexual)
3.84 (2.72–5.41)
2.63 (1.83–3.78)
3.85 (2.64–5.61)
2.61 (1.75–3.90)
Model 2 Lesbian (vs heterosexual) Bisexual (vs heterosexual)
2.03 (0.90–4.55) 4.39 (3.03–6.36)
1.67 (0.71–3.93) 2.85 (1.93–4.21)
2.40 (1.02–5.65) 4.28 (2.85–6.42)
1.93 (0.76–4.89) 2.77 (1.80–4.26)
Males (n = 2852) Model 1 Gay or bisexual (vs heterosexual) Model 2 Gay (vs heterosexual) Bisexual (vs heterosexual)
Daily smokers represented those that smoked at least one cigarette per day in the past year. Established smokers represented those that have smoked 100 or more cigarettes in their life time and had smoked at least one cigarette per day in the past year. Values shown are adjusted odds ratios (95% confidence intervals). ⁎ Adjusted for age. ⁎⁎ Adjusted for age, alcohol use, parent's education, living arrangement, sensation seeking, and risk of depression.
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unique health needs include sexual minorities (Institute of Medicine, 2011). In a representative sample of high school students from Atlantic Canada, the prevalence of cigarette use in the past year was twice as high among LGB than heterosexual adolescents. About 17% of LGB were ever daily smokers compared to 8% of non-LGB students. In the adjusted analysis, LGB students were significantly more likely to report daily cigarette use in the last year. The results shown in this study are largely consistent with the findings reported in previous adolescents' studies (Coker et al., 2010; Corliss et al., 2013; Marshal et al., 2008; Hagger-Johnson et al., 2013) and among young adults (Rath et al., 2013). In keeping with studies showing sex to be an important modifier of the association between substance use and sexual orientation (Hahm et al., 2008; Corliss et al., 2010, 2013), evidence of effect modification by sex was found in the present study. In addition, bisexual females had greater risk of tobacco use compared to heterosexual females and no significant difference was found between gay or bisexual males and heterosexual males. Using a community-based sample of US adolescents, Austin et al. (2004) found similar results among gay or bisexual boys. The preponderance of research suggests that emotional distress may in part help to explain the health disparities among sexual minorities (Almeida et al., 2009; Coker et al., 2010; Hatzenbuehler et al., 2014; Marshal et al., 2008; Meyer, 2003). Minority stress theory posits that poorer health outcomes among stigmatized minority groups are a result of excess stress due to stigma, prejudice and discrimination (Meyer, 2003). Prospective data from the Growing Up Today Study found that sexual minority youth in the United States living in states with low structural stigma were less likely to report cigarette use in the past year (Hatzenbuehler et al., 2014). Furthermore, a recent study on the role of structural stigma on substance use among sexual minority youth found that exposure to structural stigma was significantly associated with daily cigarette use (Pachankis et al., 2014). According to survey selfreport data, LGB youth were more likely to have experienced sexual abuse, parental abuse, assault at school when compared to non-LGB peers (Saewyc et al., 2006; Bontempo and d'Augelli, 2002). Such abuse has an effect on negative health behaviors, making this population more vulnerable to substance abuse (Friedman et al., 2011). Research has found that students who attended schools with more supportive environment for sexual minorities were significantly less likely to report substance use and emotional distress (Heck et al., 2011, 2014; Konishi et al., 2013). Independent research also note that tobacco industry has historically targeted sexual minority populations (Dilley et al., 2008; Washington, 2002; Smith et al., 2006, 2008; Smith et al., 2008). This study has limitations. We used sexual attraction as a measure of sexual orientation, while other measures, including sexual behavior and self-identity are available (Austin et al., 2007). Saewyc et al. (2004), in considering the pros and cons of these various measures, point out that while multiple measures are most appropriate for such research, where outcomes other than sexual behaviors are being considered, non-heterosexual behavior as a measure of orientation can exclude students who are attracted to the opposite sex and/or self-identify as non-heterosexual, but who are not yet sexually active. Saewyc and colleagues also indicates that self-identity generally follows attraction, so that if self-identity is used as a measure, some of those at risk of behaviors associated with orientation (as measured by attraction) will not be included, concluding that where survey length makes possible inclusion of only one measure, attraction is probably the best choice. In addition to this limitation, the SDUSAP is a cross-sectional survey of students in Atlantic Canada, which limits us from making causal inference. Finally, our regional results may not be generalizable to adolescents in other parts of Canada and comparability of our findings with other studies may be limited due to different ways of assessing sexual orientation (Saewyc et al., 2004; Saewyc, 2011).
Conclusion Prevalence estimates for cigarette use were significantly higher among LGB adolescent students. Notwithstanding Canada having same-sex marriage legislation since 2005, our findings are largely consistent with US based studies. These results join a growing body of evidence indicating that sexual minorities are at heightened risk of tobacco use. Smoking cessation measures that specifically target this group in ways that address their minority sexual orientation may be beneficial. While the empirical evidence of the benefits of gay-straight alliances in schools are accumulating (Heck et al., 2014), future research should address the knowledge deficit concerning culturally appropriate and effective tobacco prevention and cessation efforts for sexual minority community (Saewyc, 2011; Doolan and Froelicher, 2006). One study of 733 lesbian, gay, bisexual, and transgender youth in Canada and the United States revealed that youth felt it important that providers address the need for greater sensitivity to developmental and cultural differences among non-heterosexual youth as well as health promotions and assessment of health risks (Hoffman et al., 2009). Conflict of interest statement The authors declare that there are no conflicts of interests.
Funding This research was supported by research grants from the Canadian Cancer Society Research Institute (Grant Number 2011-701019) and the Nova Scotia Health Research Foundation (Grant PSO-EXT-20118431). Funding for data collection was provided in part by the provincial Departments of Health and Wellness in Nova Scotia, New Brunswick, Newfoundland and Labrador. References Almeida, J., Johnson, R.M., Corliss, H.L., Molnar, B.E., Azrael, D., 2009. Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. J. Youth Adolesc. 38 (7), 1001–1014. Austin, S.B., Ziyadeh, N., Fisher, L.B., Kahn, J.A., Colditz, G.A., Frazier, A.L., 2004. Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Arch. Pediatr. Adolesc. Med. 158 (4), 317–322. Austin, S.B., Conron, K.J., Patel, A., Freedner, N., 2007. Making sense of sexual orientation measures: findings from a cognitive processing study with adolescents on health survey questions. J. LBGT Health Res. 3 (1), 55–65. Barker, M., Yockney, J., Richards, C., Jones, R., Bowes-Catton, H., Plowman, T., 2012. Guidelines for researching and writing about bisexuality. J. Bisexuality 12 (3), 376–392. Bontempo, D.E., d'Augelli, A.R., 2002. Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths' health risk behavior. J. Adolesc. Health 30 (5), 364–374. Chassin, L., Presson, C.C., Sherman, S.J., Edwards, D.A., 1990. The natural history of cigarette smoking: predicting young-adult smoking outcomes from adolescent smoking patterns. Health Psychol. 9 (6), 701–716. Coker, T.R., Austin, S.B., Schuster, M.A., 2010. The health and health care of lesbian, gay, and bisexual adolescents. Annu. Rev. Public Health 31, 457–477. Corliss, H.L., Rosario, M., Wypij, D., Wylie, S.A., Frazier, A.L., Austin, S.B., 2010. Sexual orientation and drug use in a longitudinal cohort study of US adolescents. Addict. Behav. 35 (5), 517–521. Corliss, H.L., Wadler, B.M., Jun, H.J., et al., 2013. Sexual-orientation disparities in cigarette smoking in a longitudinal cohort study of adolescents. Nicotine Tob. Res. 15 (1), 213–222. Dilley, J.A., Spigner, C., Boysun, M.J., Dent, C.W., Pizacani, B.A., 2008. Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities? Tob. Control. 17 (6), 385–390. Doolan, D.M., Froelicher, E.S., 2006. Efficacy of smoking cessation intervention among special populations: review of the literature from 2000 to 2005. Nurs. Res. 55 (4), S29–S37. Friedman, M.S., Marshal, M.P., Guadamuz, T.E., et al., 2011. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. Am. J. Public Health 101 (8). Hagger-Johnson, G., Taibjee, R., Semlyen, J., et al., 2013. Sexual orientation identity in relation to smoking history and alcohol use at age 18/19: cross-sectional associations from the Longitudinal Study of Young People in England (LSYPE). BMJ Open 3 (8), e002810. Hahm, H.C., Wong, F.Y., Huang, Z.J., Ozonoff, A., Lee, J., 2008. Substance use among Asian Americans and Pacific Islanders sexual minority adolescents: findings from the National Longitudinal Study of Adolescent Health. J. Adolesc. Health 42 (3), 275–283.
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